UNDERSTANDING AND WORKING WITH COMPLEX TRAUMA & DISSOCIATION Lynette S. Danylchuk, PhD Kevin J. Connors, MS, MFT INTRODUCTION The Difficult Client Chaotic Lifestyle Frequent Crisis Calls Suicidal & Para-suicidal Behaviors Manipulative Non-Compliant/Oppositional INTRODUCTION The Borderline Client Black or White/All or Nothing Thinking Extreme Ambivalence Extreme Labiality of Affect Approach/Avoidance Self-Harm Behaviors INTRODUCTION The Dissociative Client Spaced Out/Foggy Identity Confusion Memory Problems Hears Voices History of Treatment Failures THE PROBLEM Most Mental Health Practitioners See Dissociation As Extremely Rare Dissociation is seen as DID Their Viewpoint Informs the General Public THE PROBLEM Clients with Complex Relational Trauma Receive Inappropriate Treatment Given Negative Labels Treated for Surface Symptoms TAKE HOME MESSAGE By having an expanded and comprehensive understanding of trauma based disorders and dissociative defenses, more clients will get better treatment. WHO ARE THEY? Possible Client Populations Alcohol/Substance Abuse Intimate Partner Violence Eating Disorders COMPLEX TRAUMA Impact of Trauma Natural Trauma vs. Interpersonal Trauma Loss of Safety Loss of Invulnerability Shattering of Worldview MEANING AND IMPACT OF COMPLEX INTERPERSONAL TRAUMA FREUD ON PSYCHIC TRAUMA "An experience which within a short period of time presents the mind with an increase of stimulus too powerful to be dealt with or worked off in the normal way, and thus must result in permanent disturbances of the manner in which energy operates" (1916). Phenomenological Presentation – What does it look like? PTSD Symptoms – Siegel’s Window of Tolerance Hyper-arousal Hypo-arousal Intrusive Flashbacks Window of Tolerance Window of Tolerance COMPLEX TRAUMA Relational Trauma The closer the relationship between perpetrator & victim the more devastating the damage Betrayal Loss of Trust COMPLEX TRAUMA Developmental Trauma Age of Onset Frequency of Abuse Lack of Nurturing and Healing Responses Dissociative Defenses Conceptualizations of Dissociation Disruption of self awareness Disruption of relatedness they embody painful experiences, but become autonomous by virtue of their segregation from the main stream of consciousness . . . ..(they) did not belong to the personal consciousness, were not connected to the personal perception, and lacked the personality's sense of self... ~ P. Janet DISSOCIATION Dissociative Symptomology Amnesia/ Trance States Depersonalization/ Derealization Fugue States Ego States Dissociative Identity Disorder DDNOS Phenomenological Presentation – What does it look like? Relational Symptoms Borderline features Paranoid features Narcissistic features Asocial features DIAGNOSIS Frequent Misdiagnosis 3.6 To 6.8 Years In Mental Health System Prior To Accurate Diagnosis 3.2 Diagnoses Prior To Accurate Diagnosis High Co-morbidity DIAGNOSIS Dissociation Dissociative Experiences Scale-II (Carlson & Putnam) Multidimensional Inventory of Dissociation version 6 (Dell) Somatoform Dissociation Questionnaire – 20 (Neijuis) Somatoform Dissociation Questionnaire - 5 (Neijuis) Clinical Interviews Dissociative Disorders Interview Schedule (Ross) Structured Clinical Interview-Dissociative Disorders (Steinberg) DIAGNOSIS Post Traumatic Stress Disorder LA Symptom Checklist (Foy) Trauma Symptom Checklist (Briere) Adverse Childhood Experiences Scale (Anda & Feletti) Diagnosis Differential Diagnosis Considerations Schizophrenia Bi-Polar Disorder Paranoid Disorder Major Depression Borderline Personality Disorder Psychosis DISSOCIATION & SUBSTANCE ABUSE Authors Benishek & Wichowki Population Studied N Substance Abusers 51 Tamar-Gurol, Sar, Karadag, Evren & Substance Karagoz Abusers 104 Tests Results DES 25 % >15 DES, DDIS & SCID-D 46%>30 DISSOCIATION & SUBSTANCE ABUSE Alcohol or Substance Abuse in Families Increases Likelihood of Interpersonal Violence. Intimate Partner Violence Child Abuse DISSOCIATION & IPV Authors Connors, Kemper, Hamel & Ensign Population Studied Intimate Partner Violence – Victims N 95 Tests DES, CTS, CAT Trauma History Results 31.6 % > DES 20 18.9% > DES Taxon Score .55: DISSOCIATION & IPV Intimate Partner Violence is Relational Trauma Dissociative Clients at Greater Risk of Revictimization Dissociative Clients Engage in More Violence with Battering Partners IPV-Offenders May Dissociate During Assaults DISSOCIATION & EATING DISORDERS Authors Beato, Cano,& Belmonte Dalle Grave, Tosico, & Bartocci Vanderlinden, Van der Hart, & Varga Population Studied Eating Disorders Eating Disorders Eating Disorders N 118 106 98 Tests Results DES, 30.5 % > 25 DIS-Q 22.6% had severe dissociative symptoms DIS-Q 12% pathological dissociative experiences DISSOCIATION & EATING DISORDERS Sexual Abuse May Be a Factor in the Development of Eating Disorders Traumatic Experiences More Prevalent Among Clients with Bulimia & with Anorexia Nervosa: Binge Eating-Purging Subtype ETIOLOGY Neurobiology Hyper activation of Amygdala Hypothalamus, Pituitary Adrenal Overstimulation Increased Right Temporal Lobe Functioning ETIOLOGY Neurobiology Diminished Hippocampal Functioning Impaired Broca’s Region ETIOLOGY Relational /Developmental Trauma Trauma as That Which Overwhelms One’s Ability to Assimilate & Accommodate Interpersonal vs. Natural Trauma Betrayal Trauma Childhood Abuse ETIOLOGY Disorganized Attachment Attachment Theory Styles of Attachment Effects of Attachment on Adult Relationships ETIOLOGY Dysfunctional Family Dynamics ACA Issues Dysfunctional Social & Interpersonal Learning Don’t Think, Don’t Feel, Don’t Tell Ego State Model DISSOCIATION Component Model Behavior Affect Sensation Knowledge B S A DISSOCIATION Sequential Model Ego States/Alters Across Time Degrees of Dissociative Barriers SEQUENTIAL MODEL OF DISSOCIATION TRAUMATIC EVENT TTIME IME Annie Betty Chuck Dora Baby Eek! Florence Annie DISSOCIATION Structural Dissociation Self as Process Trauma Results in a Diminished Sense of Self Tiered Levels of Dissociative Disorganization of Self ♦ Tier I: ANP & EP ♦ Tier II: ANP & EP’s ♦ Tier III: ANP’s & EP’s TREATMENT Need for On-going Support & Consultation ISSTD Treatment Guidelines Component Chapters Study Groups Annual Conference Regional Seminars www.ISST-D.org Impact of Abuse on Attachment and Relationships Disorganized Attachment Leads to Multiple Models of Attachment Attachment and Avoidance Become Enmeshed Inability to Transcend “Good Parent/Bad Parent” Paradigm Disconnection From Normal Relationships Stockholm Syndrome (Graham & Rawlings, 91) Victim Feels Threatened and Fearful for Survival Victim Feels Isolated Victim Fells Dependent Upon Perpetrator for Safety Perpetrator Shows Limited Kindness Victim Bonds to Perpetrator Victim Adopts Beliefs/Rhetoric & Perceptions of Perpetrator Externalized Locus of Control Client Symptomology Lack internal control Attempt to control others Assume responsibility for others Alternately seeks and rejects external control Externalized Locus of Control Perpetrator Dynamics (Sgroi, 82 Dysfunctional boundaries Displacement of responsibility Isolation Discounted/distorted feelings Non-validation of reality Mey, 82 ) Shame Conceptualizations of Shame Inherent sense of flawed self Shame is about Self; Guilt is about an act (Lewis, 71) Shame as the basis for defense mechanisms (Wurmser, 81) Shame as an attenuator of affect (Nathanson, 92) Shame Denial of Abuse Maintains Shame Perpetrator denial Familial /societal denial Self denial Shame Denial of Abuse Maintains Shame Therapist denial (C. Dalenberg, 2000) ♦ Fears of counter transference ♦ Fears of legal liability ♦ Fear of the overwhelming pain ♦ Silence and the failure of language Shame Shame and Powerlessness E. Erickson: Autonomy vs. Shame ♦ If not able to make change then no autonomy (powerless) ♦ If powerless to make changes (lacking autonomy), then shame filled Shame Shame and Powerlessness Nathanson: Shame vs. Pride ♦ Shame inhibits experiencing the positive affects ♦ Success leads to affect: enjoymentjoy ♦ Competence & pleasure antidotes to shame Shame Shame and Powerlessness Paradoxical relationship between shame and powerlessness ♦ Powerlessness leads to shame ♦ Shame is held to avoid powerlessness ♦ Accepting powerlessness to relieve shame Addiction to Chaos (van der Kolk, 87) Examples of Chaos Eating disorders Chemical dependency Self-injurious behavior Dysfunctional relationships Identification with aggressor Addiction to anger Alexithymia Difficulty Identifying Feelings Difficulty Expressing Feelings Affect Storm Connection to Somatoform Dissociation (Clayton , 04) INTRODUCTION Three Stage Trauma Model Safety and Stability Remembering and Mourning Reconnecting INTRODUCTION Trauma Treatment Triggers Trauma Treatment frame is safe but not too safe There will be complications Therapists will step in it. Rupture repair process is rich and necessary UNDERLYING THEMES / GUIDING LIGHTS Transference and Countertransference Non-linear Nature of Trauma Therapy Replication of Dysfunctional Trauma Dynamics Addictive Patterns of Arousal Power, Powerlessness, Choices and Shame Shift from Ordeal to Recovery THERAPEUTIC RELATIONSHIP Secure Attachment Consistent Caring Presence Sustained Connection THERAPEUTIC RELATIONSHIP Boundaries Predictable Not too rigid, not too loose Negotiable Create safe environment within which to meet STAGE ONE TREATMENT ISSUES Intrusive Flashbacks Grounding Container Imagery Divide & Put Away (Controlled Dissociation) Manipulating Memories STAGE ONE TREATMENT ISSUES Self harm Explore Intent Saying What Can’t Be Said Short-term vs. Long Term Effectiveness STAGE ONE TREATMENT ISSUES Fear of Disclosure To Be Seen is to: Give away power Be in danger Create vulnerability STAGE ONE TREATMENT ISSUES Fear of Disclosure To Say It Out Loud is to: Connect to ones’ self and one’s life Make events real Make emotions more intense STAGE ONE TREATMENT ISSUES Lack of Internal Cooperation Honor the Resistance/Honor the Fear Seeing the Whole Person as Conflicted STAGE ONE TREATMENT ISSUES Alexithymia Teaching Affective Language Develop Somatic Awareness Distinguish between hyper & hypo arousal STAGE ONE TREATMENT ISSUES Affect Modulation and Self Soothing Relaxation exercise Breathing Physical interventions Hypnotic Interventions Siphon off Energy transfer Internal support system Emotional rheostat UNDERLYING THEMES/ GUIDING LIGHTS (a reprise) Transference and Countertransference Know your own tendencies What is you and what is not you UNDERLYING THEMES/ GUIDING LIGHTS (a reprise) Non Linear Nature of Trauma Therapy Sense of progress or lack of progress Same feelings over & over UNDERLYING THEMES/ GUIDING LIGHTS (a reprise) Replication of Dysfunctional Trauma Dynamics Replay Karpman’s Triangle Lead to therapist weakening boundaries Enmeshed in client’s system UNDERLYING THEMES/ GUIDING LIGHTS (a reprise) Addictive Patterns of Arousal Chaos as defense Loss of drama = Loss of life Enmeshment vs intimacy UNDERLYING THEMES/ GUIDING LIGHTS (a reprise) Power, Powerlessness, Choices and Shame Identify options Reaction vs choice Shame Defense Holding shame holds onto the meaning and the value of the loss and abuse UNDERLYING THEMES/ GUIDING LIGHTS (a reprise) Shift from Ordeal to Recovery Recognizing the trauma is past Agency over trauma vs. being controlled by trauma Integrate vs. exorcise STAGE 2: REMEMBRANCE AND MOURNING ABOUT THE CLIENT They were traumatized They are not the trauma They are not the problem REMEMBRANCE: General Considerations Integration not Exorcism Sometimes the Bad Guys are the Best Value the Need to Identify with the Perpetrator REMEMBRANCE: General Considerations Not Changing History Dealing with what was, Grieving what was not. What was learned may (or may not) be useful in different ways in the present. What was missed needs to be learned – earned attachment, relational skills REMEMBRANCE: General Considerations Do Not Need All the Memories Use the Present to Tap into the Past Identify Repetitive Patterns of Behavior Consciousness Raising REMEMBRANCE: General Considerations Need to Understand the Meaning of the Trauma Event Unbridled expression of emotion (without attached meaning) is unhealthy and re-traumatizing Recounting without affect remains disconnected & dissociated Assembling all the components of the trauma includes the meaning assigned at the time of the trauma. (Think BASK) REMEMBRANCE: General Considerations Pacing Resist the urge to turn therapy into another ordeal The slower you go, the faster you get there Trauma is not a paced experience Trauma is subjectively felt as if there is no beginning, middle, and end Learning to pace one’s self heals of the effects of trauma REMEMBRANCE: General Considerations Safety Critical Therapeutic Issues Trauma Treatment Triggers Trauma Therapists Will Make Mistakes REMEMBRANCE: Safety Dealing with Overwhelming Emotions Grounding exercises, The power of relationship Learning about the body and mind How to calm the self, Become more present REMEMBRANCE: Safety Affect regulation Name the fear/affect Identify where in your body you are experiencing the fear/affect, Identify where in your body you are NOT experiencing the fear/affect, Shift your focus between the two REMEMBRANCE: Safety Differentiating Past from Present Cell Phones Newspapers/Magazines “Where’s the Doorknob?” Therapists Will Make Mistakes Be mindful of when & how Be able to say, “I’m sorry.” Repair of therapeutic ruptures is as important as any other piece of good therapy A golden opportunity to strengthen the therapeutic alliance REMEMBRANCE: Methods Assembling Dissociative Components Non-leading Questions When to talk about ‘why’ Exploring the recalled event REMEMBRANCE: Methods Moving Forward & Backward to Complete Beginning, Middle & End Allowing non-linear processing Develop a coherent narrative REMEMBRANCE: Methods Moving Forward & Backward to Complete Beginning, Middle & End Trauma memories tend to be a repeating loop of a portion of the event Identify the context and finding the frame of reference REMEMBRANCE: Methods Moving Forward & Backward to Complete Beginning, Middle & End All along the way, existential issues arise and need to be dealt with Stage II will often activate Stage I needs REMEMBRANCE: Methods Sharing Across Alter Personalities Metaphors for helping Metaphors to create a sense of oneness out of many and value all within REMEMBRANCE: Specialized Techniques Caveat: Tools, not panaceas. Use with wisdom and caution. Many new specialized techniques can work well with severely traumatized people, but they must be used with the awareness and cooperation of the client’s system. Severely traumatized people are avoiding their pain, etc. for a good reason. The desire to be fixed, quickly, without pain can cause therapists and clients to use a technique too much or too soon. REMEMBRANCE: Specialized Techniques Hypnosis EMDR Somatic Therapies Prolonged Exposure MOURNING: GRIEF The intensity of grief Self-soothing Key questions Therapist’s ability to stay present MOURNING: Why Me? Perpetrators and Narcissism Karpman’s Triangle RESCUER PERSECUTOR VICTIM MOURNING: What Does It All Mean? Normalize the reactions and learned behaviors. Developmental process happening within therapy Finding Strength MOURNING: Control Locus of Control Issues Explore what can and can’t be controlled Shifting shame to another areas of life give the illusion of control MOURNING: Shame Shame as inhibitor: stifles joy, happiness, any kind of vulnerability. Nathanson’s shame diagram – act out, act in, blame others, blame self. MOURNING: Shame Keeps the trauma stuck. Shame avoids Powerlessness MOURNING: Shame Therapist needs to be able to sit with the shame Explore culpability – where responsibility truly resides Explore reality of choices MOURNING: Shame Challenging Core Trauma Beliefs Identify survival response I’m bad, I deserved it Powerlessness Role within the family Stage 3: Integration Not the end of therapy, but the stage that most resembles therapy with nondissociative people. Loneliness, mourning the loss of ‘others’ inside. ‘who am I?’ questions, learning to relate as a whole person, from the inside out, finding meaning and purpose, working on relationships. The Impact of Chronic Interpersonal Trauma Strips the Ability to be in Community No attachment = No connection In the natural world, this would mean certain death To the trauma survivor this is felt as complete annihilation People exclude others who are seen as excluded in other to avoid the reality of our own personal human needs. The Impact of Chronic Interpersonal Trauma Abandonment, Shame, and Powerlessness are the key Elements Abandonment: Not wanted, not included Shame: Not worthy Powerlessness: Not able to build a bridge back The Impact of Chronic Interpersonal Trauma Therapy Builds the Bridge The Therapeutic Alliance Creates Community “Paradoxically, trauma both occurs in the context of a relationship and can only be healed in the context of a relationship” ISSTD Treatment Guidelines are available at our website www. ISST-D. org CONTACT US Lynette S Danylchuk, PhD [email protected] Kevin J Connors, MS, MFT [email protected]
© Copyright 2024